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What is a Mental Disorder?

The question of what constitutes a mental disorder is a hot issue right now because the Diagnostic and Statistical Manual of Mental Disorders is in the process of making a major revision, from IV-R to V. In that regard, the authors are considering some significant changes to the definition of mental disorder. The definition is a crucial issue for mental health professionals and society in general for many different reasons, including who has access to care and how we think about the nature of the human condition. Given the complex nature of the issues and the fragmentation and conceptual confusion in psychology (and, yes, psychiatry), it should not come as a surprise that there is much confusion and controversy regarding what exactly constitutes a mental disorder. (See, for example, this article by Gary Greenberg).

Here are some basic questions regarding the definition of a mental disorder:

Where is the line between normal variation and pathology? Are mental disorders categorically different or are do they simply exist at the extremes of a continuum?

Does having a mental disorder say anything about one's character or should it be completely separated from that, and thus the individual should not be judged or stigmatized? What if the disorder is a personality disorder? Doesn't that, by definition, say the structure of a person's character is a problem?

Are mental disorders natural kinds that can be objectively specified or are they entirely the result of social values and the cultural construction of what is normal (i.e., different values will lead to different conceptions of what is a mental disorder)?

Are mental disorders essentially like other diseases in medicine or are they a fundamentally different kind of condition?

This last question is particularly important from the vantage point of psychiatry relative to other mental health professions. Psychiatrists are, of course, medical doctors, and there is thus much pressure for psychiatry to perceive mental disorders as akin to other medical conditions. And it is the American Psychiatric Association that produces the DSM. Yet many mental health professionals, like professional psychologists, counselors, social workers, and marriage and family therapists are neither trained in medicine nor inclined to want to reduce the problems they see to dysfunctional biology.

One of my earliest articles (here in word form finalHD) grounded in the UT was on the question of what is a mental disorder and focused especially on the issue of whether mental disorders were of the same essential kind as other biological diseases. My answer was that some mental disorders are likely reducible to (neuro) biological dysfunction that produces harmful consequences. Consider, for example, a rather obvious case like Alzheimer's disease. The symptoms of disorientation, forgetfulness and poor judgment are almost certainly reducible to neurological malfunctions (e.g., tangles and plaques in the hippocampus). Other highly likely candidates for what I call mental diseases are autism, schizophrenia, severe cases of OCD, Bipolar 1. Why are these conditions probably mental diseases? Because the patterns of psychological behavior are functionally unusual and difficult to explain via general psychological theory. A more parsimonious explanation is that there likely is malfunctioning processes at the level of neurobiology.

On the flip side, there are many mental disorders that cannot be reduced to or understood in terms of biological malfunction. Instead, these conditions are maladaptive psychological patterns (often of a cyclical nature) that result in elevated (AKA clinically significant) levels of distress and dysfunction for the individual and/or society. Consider the following example:

Tina is an 18-year-old freshman. She grew up in a small, rural town and is a first generation college student with hopes of being a physician. She did extremely well in high school and has always been very driven and conscientious. However, her first semester of college did not go very well. She experienced difficulty making friends, and she was uncomfortable with the drinking and party atmosphere. She focused a lot on her studies and studied several hours a day, but she struggled to get the As she expected (her first semester grades were a 3.2). Now she is reporting problems taking tests and staying focused and is worried that she has ADD. She is starting to have trouble sleeping, as she can't fall asleep because she is constantly worrying about what she needs to do the next day. She is also having nightmares about failing out of school. She also is reporting frequent stomach aches, and she is now considering whether she should transfer to a college that is closer to home.

This narrative depicts an emerging maladaptive psychological pattern and a clinician should wonder about an anxiety, depressive, or adjustment disorder diagnosis. But her symptoms are completely comprehendible via normal psychological processes, and there is no reason to assume or presuppose any sort of biological dysfunction. (This is not to say that medication could not or should not be prescribed, only that the explanation for Tina's problems would be at the psychological level rather than the biological level).

The idea that there are mental disorders that are not bio-medical conditions might make some biomedical psychiatrists experience cognitive dissonance, but professional psychologists should embrace the idea.

I have heard of people who worried they might have cancer go to the doctor for a biopsy and find out they did NOT have cancer. A cancer doctor will "turn away" a potential cancer patient just because he or she is not sick with cancer.

But I have never heard of a psychiatrist or psychologist turning away a patient because they didn't have some sort of psychological disorder. The minute a person shows up in the psychiatrist or psychologist's offices that person (normal or abnormal) MUST HAVE a psychological disorder.

Statistically speaking, this overwhelming predominance of psychiatric patients self-diagnosing themselves correctly to go to the psychiatric offices seems HIGHLY UNLIKELY. Why do ALL cancer doctors tell some patients that they do not have cancer but NO psychiatrists nor psychologists turn away any patients? Statistically speaking, it's impossible that every single patient who walks into a psychological or psychiatric office has a mental disorder but I have not personally heard of, read about, or seen media representations of any psychologist or psychiatrist turning away a patient for being mentally healthy and mentally well.

If you conducted today the same experiment from the 1960s where the psychiatrists pretended to experience a bunch of symptoms and were held in mental hospitals as a result, you would find the same or even a higher rate of hospitalization, I suspect.

Again, a difference between a cancer doctor and a psychiatrist is that just because the patient "feels like they have cancer," the cancer doctor doesn't prescribe a course of radiation therapy. The cancer doctor kicks the well person out of the office. But the psychiatrist would say that because the person "feels mentally ill" the patient should be given psychiatric treatment. Again, there are no objective standards for diagnosing the person. Just "feeling mentally ill" is enough to get a person diagnosed as mentally ill but "feeling cancerous" is not enough to get a person diagnosed as having cancer.

Statistically speaking, it's impossible for EVERY SINGLE PERSON who shows up in a psychological office to be mentally ill yet I have never seen any evidence of a psychiatrist or psychologist telling a person that due to their mental wellness and lack of a mental disorder, they don't need psychiatric treatment.

To Anonymous:
You raise a number of good points in your comment. It certainly is the case that there is a difference between 'cancer' and mental illness. However, I do need to make a point about the analogy you are drawing. While I agree that the vast majority of folks who present to a clinician's office feeling mentally ill receive a diagnosis, it is also the case that many folks believe they have a certain kind of mental disorder that they do not have. Consider the case in the example. As one who works with college students, I see many who believe they have ADD, but further assessment reveals an anxiety disorder. Thus, it is certainly the case that people can believe they have a mental illness diagnosis, but in fact do not.

Three other issues to consider.

First, subjective distress is an important element of illness, both biological and psychological. If an individual went to a physician complaining of significant pain, but no cause could be found, they would still be treated as a patient.

Second, psychiatric diagnoses are DESCRIPTIVE in nature, rather than eitological. That is, they are defined simply by the presence of symptoms, not by causes. This is a much scientifically weaker categorization system than one based on cause (but clinicians needed a reliable language first for diagnosing folks).

Third, as a professional psychologist, my treatment is only very loosely informed by an individual's DSM diagnosis. My goal as a treating psychologist is to enhance adaptive living. Knowing that some suffers from Major Depressive Disorder or Generalized Anxiety Disorder only informs me a little bit when it comes to how I work with them to improve. I am currently working on a system that I think matches the kinds of problems in living people have with treatment in a way that advances the DSM...